Pressing Needs Facing Health Care Social Work PROFESSIONAL RESEARCH BASE

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1 I S S U E Summer J U N E PracticePerspectives The National Association of Social Workers 750 First Street NE Suite 700 Washington, DC SocialWorkers.org Stacy Collins, M S W Senior Practice Associate scollins@naswdc.org Strategies for Strengthening Health Care Social Work in the Health Reform Era 2013 National Association of Social Workers. All Rights Reserved. As the U.S. health care system undergoes rapid change, health care social work is also transforming at a swift pace. Under the auspices of NASW and the Society for Social Work Leadership in Health Care (SSWLHC), social work leaders and health experts i from around the nation convened in Washington, DC on February 25th 2013, to discuss the current state of health care social work and develop recommendations for strengthening this fundamental area of practice. Meeting participants represented practice settings across the health care continuum including, acute care, behavioral health, oncology, palliative and hospice care, pediatrics, primary care, public health, and veteran s health. Pressing Needs Facing Health Care Social Work PROFESSIONAL RESEARCH BASE A common theme emerged regarding the need for an enhanced research base to substantiate the value of social work interventions in health care. An insufficient research base affects health care social work practice in a number of ways. Health care institutions, once driven by volume of care, are focused increasingly on reducing utilization and improving patient outcomes. This change necessitates stronger evidence of social work effectiveness. And unlike medicine and nursing, inpatient social work departments are often challenged by the lack of infrastructure to support research studies. To meet cost containment objectives, public and private payors are also pushing for credible effectiveness data, particularly as other (often less costly) health and behavioral health providers assume traditional social work roles. A strong research base, or lack thereof, also affects leadership opportunities. For example, social workers are often absent from public health leadership discussions, due in part to the profession s underdeveloped scientific base. MANAGEMENT AND ADMINISTRATION A stronger social work presence in health care management was also identified as a critical need facing the profession. Experienced social work managers can elevate the profile of the profession and preserve and create health care social work jobs. The robustness of many children s hospital social work departments can be attributed to the presence of social work directors whose career trajectories have taken them from front-line positions to management roles.

2 It no longer matters how many people we see. We need to document the impact on patients and families of the work we do. James Zabora There are not enough social workers seeking [behavioral health care management and administrative] positions. John Mistrangelo GREATER PROFESSIONAL DISTINCTION With more disciplines poised to assume traditional social work functions, health care social workers are challenged to demonstrate their distinction from other health care providers. Social workers need to recognize the importance of interdisciplinary, team-based care while emphasizing their distinctive training and skills. Without distinguishing its unique capabilities, the social work profession may be relegated to a subordinate status within health care institutions, rather than being viewed as a vital contribution to patient health and well-being. SPECIALIZED TRAINING The changing health care landscape calls for enhanced social work education and training. For example, the profession must address the shortage of social work educational opportunities that reflect the depth and scope of palliative care, as the resources currently available are insufficient for this growing area of social work practice. Greater availability of social work leadership training is also necessary, to cultivate a future workforce of social work managers in health care settings. And, as heath care becomes more technologically driven, social workers need additional training in technology skills, particularly in telemedicine, video conferencing and social media. Emerging Opportunities for Social Workers in Health Care Settings DISTRESS SCREENING FOR INDIVIDUALS WITH CANCER Distress screening, which soon will be mandatory at all Commission on Cancer (CoC) accredited cancer centers, is a unique opportunity for social workers to assume a leadership role in the provision of an essential health care service. The CoC mandate is based on evidence indicating that cancer-related distress is a nearly universal experience, which, until recently, has been largely ignored by health care providers. Beginning in 2015, distress screening must be offered at pivotal visits, which may include initial consultation, pre and post-surgery, initiation of chemotherapy, and completion of active treatment. Social workers are largely responsible for responding to patients experiencing high levels of cancer-related distress. With nearly 1.7 million new cancer diagnoses each year in the U.S. (American Cancer Society, 2013), the opportunity to demonstrate the effectiveness of social work interventions is significant. Demonstrating the benefit of distress screening for individuals with cancer also positions social workers to advocate for expansion of this service to patients with other chronic conditions. EMERGENCY DEPARTMENT SERVICES Hospitals are increasingly employing social workers in emergency departments (Van Pelt, 2010). Pediatric hospitals are at the cutting edge of this area of practice. Most free-standing children s hospitals have 24-hour social work coverage in the emergency department, where they provide mental health evaluation, stabilization, assessment for suicidal ideation and drug/ alcohol use, and psychosocial support and consultation for trauma and family violence cases. Emergency department social workers are often the primary coordinators of psychiatric crisis teams in children s hospitals. They frequently serve as the bridge between the patient and the family and they ensure the patient s safe transition back to the community. More recently, hospitals have explored the use of social workers in emergency departments to address the psychosocial concerns of individuals without urgent medical needs that require emergency care or admission (Auerbach & Mason, 2010). SPECIALIZED SOCIAL WORK CLINICAL INTERVENTIONS Specialized social work clinical interventions, such as psychoeducation, cognitive-behavioral intervention, disease management groups, and short-term psychotherapy during hospitalization, hold the potential for improving outcomes while reducing cost and utilization. Palliative care is also an emerging social work clinical specialty. People with serious or life threatening illnesses can benefit from palliative care, which can be integrated into patient care beginning at the time of diagnosis until the end of life. This specialty area offers social workers the opportunity to employ their generalist and specialist training, as well as their ecological viewpoint. POST-DISCHARGE CARE COORDINATION Historically, hospital discharge planning has

3 been a social work function. But until recently, hospital social workers had little contact with a patient post-discharge - and often no verification that a treatment plan had been followed. Hospital social workers have challenged this limited role by expanding into care transition functions. Rush University Medical Center (Rush) has developed an evidence-based model, the Enhanced Discharge Planning Program (EDPP), a social work-led, post-discharge intervention to assist older adults in safely transitioning back to the community. Through telephonic care coordination, hospital-based social workers ensure full implementation of the discharge plan, assist with arranging community resources and follow-up appointments, and address issues that arise for people with complex conditions. A randomized control trial of the EDPP showed positive results, including increased medication understanding, decreased stress, and better adherence to scheduling and attending follow-up medical appointments (Altfeld et al., 2012). By ensuring safe transitions from hospital to home, Rush social workers have demonstrated their value to the institution. EDPP has been replicated at sites across the country. PRIMARY CARE SETTINGS/MEDICAL HOMES Social workers are increasingly present in medical homes (also known as health homes) and other primary care settings. These settings allow social workers to combine their behavioral health training with their health promotion and disease prevention skills. The Veterans Administration (VA) has developed a unique medical home model, the Patient Aligned Care Team (PACT). PACT teams are multi-interdisciplinary, with social workers serving as health care advocates, case managers and mental health clinicians. The PACT model demonstrates the breadth of health care social work functions. COMMUNITY-BASED MENTAL AND BEHAVIORAL HEALTH SERVICES Mental and behavioral health administrators recognize the broad benefit of social workers, who bring experience in community-based treatment, awareness of the social determinants of health, and an understanding of the interdependence of physical and mental well-being. Like their hospitalbased colleagues, mental and behavioral health social workers focus on maintaining clients in the community, reducing readmissions, ensuring access to coordinated care, and serving as a bridge between the client and the health care institution. Mental and behavioral health is a growth area for social workers, fueled by the Affordable Care Act s (ACA) significant investment in prevention and treatment of substance abuse and mental health disorders, and the value that the mental and behavioral health sector places on social work services. PREVENTION AND PUBLIC HEALTH INTERVENTIONS Much of health care social work is preventionbased, but the profession often fails to identify it as such. Supporting HIV medication adherence, providing home visitation services for at-risk mothers and newborns, and addressing childhood obesity are all examples of social work prevention and public health interventions. Social workers are well-positioned to take a leadership role in new ACA prevention programs. Furthermore, new research fields, especially patient-centered outcomes research and community-based participatory research, offer an opportunity for social workers to contribute to the prevention and public health research base. New Opportunities in the Affordable Care Act ACCOUNTABLE CARE ORGANIZATIONS (ACOs) AND HEALTH HOMES The ACA invests heavily in these care delivery models, which seek to improve patient outcomes and lower health care costs through greater integration of acute care, primary care and other community-based services. The ACA s demonstration projects involving ACOs and health homes open a window for social workers to use their skills in patient navigation, mental and behavioral health integration, and care coordination (Collins, 2011). To thrive, ACOs and health homes will need to rely heavily on this social work skill set. Social workers involved in these models, whether as mental and behavioral health clinicians or as care coordinators, are also well positioned to advocate for the use of qualitative outcome measures to gauge patient satisfaction and well-being. On a day-to-day basis, we work in teams with our health care colleagues and while there are many shared aspects of the specialty, our skill sets are unique. Whereas physicians and nurses may assess for psychosocial needs, they generally do not have the depth of training that allows them to intervene with the expertise of a trained social worker. Terry Altilito [Social work directors] have become influential leaders within their institutions and many have advanced to key hospital administrative positions. Ed Woomer

4 The unique opportunity offered by distress screening will help us make the case that social work is an essential component of health care delivery, and not simply a value-added service. Krista Nelson Just as we are integral to post-discharge care coordination, social workers need to be part of medical homes and ACOs, where we can combine our behavioral health training with our health promotion and disease prevention skills. Robyn Golden CMS INNOVATION CENTER GRANTS The CMS Innovation Center was created to develop and test new health care delivery and payment models. Health care social work leaders have been successful in designing and implementing projects that have received Innovation Center funding. The Illinois Transitional Care Consortium received a grant for its Bridge Program, a multi-site project using the Rush social work discharge intervention. dupont Hospital for Children in Delaware received a grant to establish pediatric health homes, to reduce asthma-related emergency department use and inpatient admissions among pediatric Medicaid patients. Social workers are involved in management and supervisory functions for the pediatric health home project. Partners in Care Foundation, a community-based, social work-led organization, received an Innovation Center grant to reduce hospital and nursing home admissions among Medicare beneficiaries in Los Angeles County. Innovation Center grants provide an opportunity to build the evidence base for models of care that can be used broadly by the social work community. MEDICARE WELLNESS BENEFIT: Through the ACA, Medicare beneficiaries are now entitled to free annual wellness visits with their primary health care provider. These visits include a variety of interventions, including depression screening. Although such screening must be performed by physicians, nurse practitioners, or physician assistants, social workers may provide the requisite follow-up assessment and treatment, for beneficiaries who screen positively for depression. For social workers in primary care settings, providing these psychosocial services demonstrates both their value to the health care team and the effectiveness of their interventions. Research has shown that depression can exacerbate other chronic health conditions, and reducing depression can lower overall health care costs. Recommendations for Strengthening Health Care Social Work RESEARCH RECOMMENDATIONS Design research studies that generate outcomes data on social work effectiveness, including measurement of readmission, adherence, utilization and patient satisfaction Encourage the development of research infrastructure in hospital social work departments to facilitate studies Develop and implement research studies in the social work prevention and public health field, particularly studies employing patient-centered outcomes research and community based participatory research techniques Continue to build the evidence base that supports the social role in post-hospitalization care coordination PRACTICE RECOMMENDATIONS Promote consistent use of evidence-based social work interventions in all health care settings Promote social work participation in emerging ACA opportunities, including medical homes/ health homes, ACOs, as well as Innovation Center programs testing re-admission prevention and care coordination models Foster social work leadership in distress screening for individuals with cancer and encourage social work advocacy to expand distress screening to individuals with other chronic health conditions Strengthen clinical supervision within health care settings Establish an academic and practitioner workgroup to analyze industry needs and opportunities for social workers across the health care continuum LEADERSHIP DEVELOPMENT RECOMMENDATIONS Develop training programs to prepare social workers to move into middle management positions in health care and behavioral health care settings Establish leadership training as a core competency in social work education Support a national social work certification in health care leadership Establish formal mentoring programs among health care social work managers and administrators SOCIAL WORK EDUCATION/CONTINUING EDUCATION RECOMMENDATIONS Devote resources to enhance and enrich social work education at all levels, to insure that generalists and specialist training reflects the complexity and scope of health care social work across the continuum Educate social work students and recent social work graduates on the many opportunities -both in front-line clinical and management-level positions - within the health and behavioral health care systems

5 Include health care social work as a component of reaccreditation for schools of social work Increase the number of social work schools that offer health care concentrations in their MSW programs and increase the availability of health care social work field placements Strengthen health care technology skills among social workers, particularly in telemedicine, video conferencing and social media Enhance the care coordination and case management skills necessary for social workers in the current health care environment Expand educational opportunities in emerging social work practice areas, including palliative care, primary care, emergency care, and behavioral health integration POLICY/ADVOCACY/REGULATORY RECOMMENDATIONS Push for state regulations that mandate social work inclusion in Medicare and Medicaid ACOs Advocate for reciprocity among social work state licensure boards, to allow greater mobility for health care social workers Work with CMS to modify the clinical social work scope of practice to include both mental health provider and health care provider Advocate for social work effectiveness research funding within all federal agencies that fund health research Advocate for social work use of the health and behavior assessment and intervention codes (H&B codes), to provide fair reimbursement for social work services PUBLIC EDUCATION RECOMMENDATIONS Educate the public about the distinctive skill set of health care social workers, emphasizing how social work education and training enhances the services provided to patients, families and health care institutions Educate insurance carriers on the cost saving potential and effectiveness of social work interventions Educate employers and allied health professionals on the roles, expertise, and value added functions of health care social workers across the health care continuum Educate policymakers and health care leaders about the suitability of social work skills in meeting the growing need for coordinated care, particularly among vulnerable older adults Inform all audiences about the central role of health care social workers in addressing the social determinants of health References Altfeld, S.J., Shier, G.E., Rooney, M., Johnson, T.J., Golden, R.L., Karavolos, K., Perry, A.J. (2012). Effects of an enhanced discharge planning intervention for hospitalized older adults: A randomized trial. The Gerontologist. Advance online publication. doi: /geront/gns109. American Cancer Society. (2013). Cancer Facts & Figures Atlanta: American Cancer Society. Auerbach, C. & Mason, S. (2010). The value of the presence of social work in emergency departments. Social Work in Health Care. 49(4). Collins, S. (2011). The medical home model: What is it and how do social workers fit in? Washington, DC: National Association of Social Workers. Van Pelt, J. (2010). Making caring connections, cutting costs: Social work in the emergency department. Social Work Today. 10(6). i Terry Altilio, Social Work Coordinator, Dept. of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York, NY Robyn Golden, Director of Health and Aging, Rush University Medical Center, Chicago, IL John Mistrangelo, Vice President and CEO, Adventist Behavioral Health, Rockville, MD Krista Nelson, President, Association of Oncology Social Work, Portland, OR Betty Ruth, Clinical Associate Professor, Boston University School of Social Work, Boston, MA Carol Sheets, Acting Chief Consultant, Care Management and Social Work Services, Dept. of Veterans Affairs, Washington, DC Ed Woomer, President, Society for Social Work Leadership in Health Care, Wilmington, Delaware James Zabora, Director, Life with Cancer program, Inova Health System, Fairfax, Virginia Within the Patient Aligned Care Team (PACT) medical home model, VA social workers screen highrisk Veterans across the age spectrum and provide case management for a variety of conditions including chronic illness, PTSD, serious mental illness, substance use, and women s health needs, such as obstetrics and gynecology. PACT social workers also address concerns related to unstable housing, limited support systems, low-income, and frequent hospitalization. Carol Sheets Our profession s cultural responsiveness, ecological viewpoint and our skills in community organizing, integration, navigation, and client empowerment play an important and recognized role in the new health care arena. Betty Ruth

6 Center for Workforce Studies & Social Work Practice Recent Publications Children & Families Social Work Services with Parents: How Attitudes and Approaches Shape the Relationship Clinical Social Work 2012 Medicare Updates for Clinical Social Workers Clinical Social Workers and 5010: Frequently Asked Questions Clinical Social Workers Be Aware: Version 5010 is Coming Documenting For Medicare: Tips For Clinical Social Workers Retiring? Tips For Closing Your Private Practice Risk Management In Clinical Practice Education Addressing the Educational Needs of Older Youth Gangs: A Growing Problem in Schools Leadership and Organizations Beyond Survival: Ensuring Organizational Sustainability NASW Leadership in Palliative & Hospice Social Work Organizational Integration of Cultural Competency: Building Organizational Capacity to Improve Service Delivery to Culturally Diverse Populations Organizing For Office Safety Poverty The Affordable Care Act: Implications for Low and Moderate-Income Women s Health and Well-Being Overcoming Economic Hardships Workforce & Career Development Accountable Care Organizations (ACOs): Opportunities for the Social Work Profession Career Coaching: A Valuable Resource For Social Workers Furthering Your Social Work Education: Obtaining A Doctorate Negotiating A Higher Salary Networking: Finding Opportunities for Career Development Securing The Social Work Job You Seek: Advice For The Interview Process Setting and Maintaining Professional Boundaries State Health Insurance Exchanges: What Social Workers Need to Know The Value Of Social Work Mentoring Transitioning Across State Lines: Licensing Tips Beyond 9 To 5: Working As A Consultant Practice Perspectives Summer June First Street NE, Suite 700 Washington, DC SocialWorkers.org

The Medical Home Model: What Is It And How Do Social Workers Fit In?

The Medical Home Model: What Is It And How Do Social Workers Fit In? I S S U E 10 A P R I L 2 0 1 1 PracticePerspectives The National Association of Social Workers 750 First Street NE Suite 700 Stacy Collins, MSW Senior Practice Associate scollins@naswdc.org Washington,